Ocular Urgencies and Emergencies Mindy J. Dickinson, OD Midwest Eye Care, PC Omaha/Council Bluffs

Objectives Triage Procedure Emergent vs Urgent Using symptoms to help decide urgency Overview of acute eye problems What symptoms cue you in to problem What history is important How soon should patient be seen What does the problem look like

Triage Screening process Assess patient’s problem to determine if and how soon patient needs seen Done over phone or if patient walks into clinic Need to decide if problem is emergent, urgent, or routine

Triage Questions should ask: 1) Chief complaint or symptoms ? got something in eye, matted shut, red, tearing, pain, blurred vision, loss of vision, double vision, floaters/flashes 2) When did it happen ? How long how long has problem been going on ? 3) Severity ? Worsening ? 4) Have they tried any treatments already ? Irrigated the eye, old antibiotic they had at home, artificial tears 5) Did someone tell them to come in ? Dr in ER, their PCP, etc

Triage Must get patient’s information Be professional, calm Name Date and time of call Telephone number patient can be reached at May want to get idea how long they can be reached at that number so we get back to them in time Be professional, calm Exhibit care and concern

Triage Urgency usually greater when problem is Severe Worsening Recent onset Affecting vision Referred by another doctor Patient is very concerned

Triage Emergent Situation Urgent Situation Routine Situation Requires immediate action Come to clinic or go to ER same day Urgent Situation Requires patient be seen within 24-36 hours Routine Situation Requires patient to be seen within few days to a week

Using Symptoms to help you… Redness Discharge Foreign Body Sensation Itching Burning Eye Lid Swelling “edema” Light Sensitivity “photophobia” Pain Changes in Vision or something blocking Vision

Causes of Redness Blepharitis Conjunctivitis Episcleritis/Scleritis Dryness/Exposure Trichiasis/Entropion Uveitis Subconjunctival Hemorrhage Contact Lens related problems Corneal Ulcer Corneal Abrasion/Recurrent Corneal Erosion Foreign Body Chemical Burns/Welding Burns Acute Glaucoma

Discharge Causes of Discharge Tearing, thick mucus, stringy Green or yellow Lots or just a little Causes of Discharge Conjunctivitis (bacterial, viral, allergic) Blepharitis Hordeolum (stye) Corneal trauma – scratch, foreign body, ulcer, chemical burn contact lens related problem Dry Eye Disease

Foreign Body Sensation Scratchy “gravel in eye”, “eyelash in eye” Causes of FBS Foreign body in cornea or conjunctiva Trichiasis (eye lash rubbing on eye) Corneal or Conjunctival Abrasion Dry Eye Disease Conjunctivitis Contact Lens Intolerance

Itching/Burning Usually less urgent Causes Blepharitis * Allergy * Conjunctivitis * Dry Eye Disease * Contact Lens intolerance Keratitis (corneal inflammation) Inflamed pinguecula or pterygium

Swelling “edema” Causes of lid edema Eyelid swelling Conjunctival swelling “chemosis” Causes of lid edema Conjunctivitis Corneal disease (foreign body, abrasion, ulcer) Hordeolum (stye) Preseptal Cellulitis/Cellulitis Blunt Trauma Contact Dermatitis Chemical exposure/burn Herpes Zoster (shingles)

Light Sensitivity “Photophobia” Indicates eye inflamed Corneal and/or Anterior Chamber involvement More urgent !! Causes of Photophobia Corneal trauma – abrasion, ulcer, foreign body, CL overwear Keratitis Herpes Simplex Keratitis Uveitis Dry Eye Disease

PAIN More severe the pain = more urgent !!! Grading scale 1 to 10 (10 is worst ever) Superficial, sharp pain Deep, achy, throbbing pain On eye movement? Constant vs intermittent? History of trauma? More severe the pain = more urgent !!!

Vision Affected or Unaffected If affected = more urgent!! Hazy, blurred, missing half of vision, black spot in middle Floaters, flashes of light, “curtain” Double vision Constantly reduced vs comes and goes May be associated with pain or be painless Even if not affected now… is vision threatened ?

Vision-Threatening vs. Not Vision-Threatening Conjunctivitis Episcleritis Blepharitis Trichiasis Dry Eye Syndrome Subconjunctival Hemorrhage Hordeolum/Chalazion

Potentially Vision Threatening Emergencies that HURT Corneal Ulcer Corneal Abrasion Chemical Burn Foreign body Herpes Simplex Herpes Zoster Uveitis Cellulitis Trauma Hyphema Orbital Fracture Ruptured Globe Acute Glaucoma These are all associated with pain, redness, &/or photophobia All are EMERGENCIES!!

PAINLESS Loss or Threats to Vision No pain or redness, but may have… New Floaters Flashes of Light Curtain in Vision Significant reduction in overall vision “Smudge” in central vision Half of vision missing Vision dimmed out, went black, now its back Double vision (diplopia) All are EMERGENCIES !! Posterior Vitreous Detachment Retinal Tear Vitreous Hemorrhage Retinal Detachment Retinal Vascular Occlusion Amaurosis Fugax Wet Macular Degeneration Macular Edema Optic Nerve Swelling Cranial Nerve Palsy Impending Stroke

Other Helpful Information… Do they Wear Contacts ? Sleep in lenses? Are lenses old? More urgent !! Tell patient to take lenses out !! Trauma ? Previous Treatments tried ? If not working or problem worsening = more urgent If haven’t tried anything, may be able to make some suggestions (artificial tears, cold or warm compresses)

Other Helpful Information… Ocular history – if any of these, likely more urgent Corneal abrasion - risk of recurrent corneal erosion Corneal ulcer Herpes simplex Uveitis Trichiasis Recent Posterior Vitreous Detachment High Myopia Lattice Degeneration s/p Ocular Surgery or Laser Macular Degeneration

Other Helpful Information Ocular History History of a chronic problem like Blepharitis or Dry Eye disease may reduce urgency Ask patient what they have been trying to do for relief and what is and isn’t working May be able to make suggestions over the phone or at least to get patient by until exam time in a few days

Other Helpful Information Referral from another doctor Schedule based on need requested by other doctor If urgent request, need to get worked in regardless of schedule Get Dr’s name, phone number, address, fax Patient’s level of anxiety or concern Even though may be less urgent problem, good care may mean seeing patient to ease concern

When in doubt … Ask your doctor!! Would rather error on side of caution and see sooner Dr may know more about patient’s history to recommend sooner or later appointment Even if less urgent (ie. broken glasses), Dr’s schedule may allow for sooner appointment and therefore better customer service

Overview of Acute Eye Problems Objectives: Familiar with name of problem Familiar with what problem might look like Symptoms associated with problem Urgency of examination

Subconjunctival Hemorrhage Broken blood vessel causing blood to collect under conjunctiva Symptoms Confluent Redness No discharge, pain No change in vision

Confluent Redness in Subconjunctival hemorrhage

Subconjunctival Hemorrhage History of trauma ? Use of blood thinners ? Coumadin, Plavix, Aspirin High dose of ibuprofen, naproxen, vitamin E Recurrent ? NOT URGENT may be able to triage over phone Patient may need Dr for reassurance

Conjunctivitis Inflammation of conjunctiva Injection of bulbar and palpebral conjunctiva DISCHARGE !

Types of Conjunctivitis Bacterial * Viral * Allergic * Blepharoconjunctivitis (associated with Blepharitis) Keratoconjunctivis Sicca (Dry Eye Syndrome) Contact Lens Related Chlamydial Gonococcal Vernal/Atopic

Symptoms of Conjunctivitis Mild to moderate redness Scratchy, Burning, Stinging, Sticky, Itchy DISCHARGE Tearing, Watery, Stringy, Mucoid, Purulent (LOTS) “eyelids matted shut upon awakening” Little to no affect on vision If affected, usually “hazy”, intermittent Little to no pain Perhaps hx of exposure to someone else with “pink eye” or recent cold symptoms

Mucopurulent Conjunctivitis

Viral Conjunctivitis

Conjunctivitis associated with Contact Lenses

Sub-Epithelial Infiltrates in Viral Conjunctivitis

Conjunctivitis Usually Self-Limiting !!! Going to get better no matter what Even without treatment, most will resolve in 10-14 days More are viral than bacterial If vision affected, more pain, or more severe symptoms --- should see same day Also if not getting better, could be misdiagnosed --- see urgently

Conjunctivitis – Treatment Antibiotic drops (if bacterial) Anti-allergy drops (if allergic) Preservative-Free Artificial tears (chilled tears good for inflammation and very soothing) Cold compresses Oral NSAID (ibuprofen) Good hand washing Discontinue contact lens use (at least temporarily)

Keratoconjunctivitis Sicca - “Dry Eye Syndrome” Poor tear film covering eye Due to not enough production or evaporating too quickly Leads to exposure, mucus build up, and inflammation of cornea and conjunctiva Symptoms Burning, stinging, tearing, fluctuations in vision, foreign body sensation, stringy mucus

Dry Eye Syndrome CHRONIC problem symptoms can vary from mild to severe Mild urgency – see same day or next day if not already diagnosed If already diagnosed but worsening, then a few days okay

Tear Break Up in Dry Eye Syndrome

Eye Lid Disease - Blepharitis Inflammation of lid margin Crusting along lashes Clogging of Oil Glands (meibomian glands) “Red-rimmed” eyes Chronic recurrent issue Symptoms: Burning, itchy, mattering, crusty, foreign body sensation, red

Blepharitis Anterior blepharitis Posterior blepharitis

Blepharitis Chronic Disease with good days and bad days Patient’s history may help you know how soon patient needs soon What treatment are they already on Mild to Moderate Urgency – 24 to 72 hours

Trichiasis Misdirected eyelashes rubbing on eye Recurrent Scratchy, foreign body sensation, tearing, mild discomfort See within 24 hrs

Entropion Eye lid turned inward Lashes rub on eye Scratchy, foreign body sensation, tearing, mild discomfort See in 24-36 hours Tx with surgery may tape lid out or use ung to get by until surgery

Hordeolum “stye” Blocked eyelid gland Localized infection/inflammation Eyelid is very tender and red with localized swelling See in 24-36 hours if vision not affected and eye still open If vision affected or cannot open eye = emergent

Chalazion Not Urgent, may be seen in few days to week Old blockage of gland in eyelid No longer inflamed Non-tender, non-red bump in eyelid that “been there for a while” Not Urgent, may be seen in few days to week Ask if did hot packs Warn likely won’t be removed that day of first office visit

Preseptal Cellulits vs Cellulitis Spreading of infection / inflammation into surrounding eyelid tissue or into orbital socket and into brain May start as stye or with trauma Symptoms: SIGNIFICANT eyelid swelling Red, hot skin Pain, Fever In orbital cases, causes decreased vision, pain on eye movement, afferent pupil defect, proptosis (bulging of eye) EMERGENCY!!

Preseptal Cellulitis second to Trauma

Orbital Cellulitis

Allergic Reaction of Eyelids Lid edema Scaling of eyelid skin Red, warm skin Painless!! Itchy Mild urgency 24 to 36 hours

Epicleritis vs Scleritis - inflammation of episcleral or scleral layers of eye EPISCLERITIS not serious Eye is mildly pink No discharge Vision not affected None to minimal pain URGENT – 24 hours SCLERITIS very serious Very Red but no discharge Photophobic Very Painful – can wake pt from sleep, cause decreased appetite, pain may radiate into temple or brow Vision may be decreased EMERGENT – right away

More Superficial Injection in EPISCLERTIS

Episcleritis

Scleritis

Corneal Foreign Body Metal embedded in cornea Often get Rust Ring and surrounding edema Tearing, pain, light sensitivity, redness Hx of grinding metal See right away!

Corneal Abrasion History of trauma Significant pain and tearing Photophobia Blurred vision EMERGENCY – see right away !

Recurrent Corneal Erosion Corneal epithelium sloughs off without any new history of scratching it Usually happens upon awakening in morning Have history of either corneal abrasion anterior basement membrane dystrophy Very painful Tearing, red, swollen lid ** see that day

Corneal Ulcer Epithelial defect with infiltration by immune cells – may be inflammatory or infectious Non-light passing opaque lesion Symptoms are severe PAIN, redness, tearing, photophobia Important history – CL wearer? Sleep in CL? Swim in CL? How old are CL?

Corneal Ulcers

Corneal Ulcers If suspect ulcer, see ASAP!! Hypopyon may be present (pus in anterior chamber) If suspect ulcer, see ASAP!! Patient may need cultures, seen daily until showing improvement

Corneal Ulcers

Herpes Simplex Dendritic Keratitis Cold sore virus causing ulceration of cornea Very classic pattern of staining – dendritic “tree-branching” lesions VISION THREATENING! Severe Pain, Redness, Photophobia Unilateral Can be recurrent

Herpes Simplex EPITHELIAL Keratitis

Herpetic Keratitis Often misdiagnosed as pink eye or corneal ulcer If pink eye that not getting better – could be suspicious Likely to recur If have this history, bring patient in same day

Herpes Simplex STROMAL Keratitis Due to immune system reactivating in response to virus, not the virus itself in the cornea Cornea edema, anterior chamber reaction, but no ulcer ++ Pain, Photophobia, Reduced vision See ASAP, especially if hx of HSV

Herpes Zoster = “Shingles” Related to chicken pox Sores on skin on 1/2 of body, torso or face – usually forehead and eyelids Usually preceded by pain or tingling while combing hair or along eyebrow Can cause eyelid sores, conjunctivitis, corneal plaques, or uveitis If immunocomprimised, can also cause retinitis or neuritis

Shingles Patient usually comes as a consult from family practice doctor If reduced vision or red eye, need to see ASAP If just confirming no ocular involvement, likely okay to see within 24 hours

Uveitis Inflammatory reaction in anterior chamber of eye Also called “iritis” or “iridocyclitis” May be idiopathic or due to underlying systemic disorder Often initially misdiagnosed as “pink eye” by PCP Symptoms: Redness, Photophobia, Deep Throbbing/Aching pain “headache behind eye”

Uveitis Potentially threatening to vision Can cause cataract or glaucoma May involve retina, optic nerve, macula Often recurrent and patients can tell when it comes back – so if history of uveitis – see same day Based on symptoms alone, but also history, see same day

Hyphema Blood in anterior chamber due to blunt trauma Immediate risk of pressure spike, rebleed, retinal detachment, traumatic optic nerve damage

Hyphema Need to see these patients right away Put on bed rest until blood clears Long term risk of traumatic cataract and glaucoma

Penetrating Injury History of Trauma Excess tearing Extreme Pain True EMERGENCY!! When use fluorescein dye, see a stream of aqueous seeping out and washing it away “seidel postive”

Penetrating injury Manipulate globe as little as possible!! Do not check IOP Place shield over eye Requires immediate Surgical Referral

Sutured corneal laceration

Chemical Burn – Acidic or Alkali POTENTIALLY VISION THREATENING! 1st thing to tell them to do over the phone is IRRIGATE, IRRIGATE, IRRIGATE ! ( before ever coming in to the office) At least 20-30 minutes if wearing contact lens, irrigate for 5 minutes or so, then remove lens and continue to irrigate for another 25 minutes Then come to office or go to ER right away !

Chemical Burns Mild = Red eye (good prognosis) Severe = White eye (poor prognosis) Expect to see eyelid edema burns of periocular skin conjunctival chemosis & hyperemia conjunctival abrasion corneal staining – mild irritation to complete loss of skin If severe – get blanching of conjunctiva – no blood/oxygen getting to eye or cornea – BAD !!

ACUTE Glaucoma Sudden Significant Increase in IOP High IOP (usually 50 or greater) Due to blockage of drainage system Angle closure, inflammatory, neovascular Hx of high hyperopia, narrow angles, proliferative diabetic retinopathy, central retinal vein occlusion Symptoms (SEVERE) Pain, Headache (brow ache), Nausea, Vomiting, Red Eye, Blurred Vision

Acute Glaucoma See ASAP Work in ahead of all other patients Need to get pressure down right away to prevent permanent vision loss (from central retinal artery occlusion – not from glaucoma damage to nerve)

Acute Glaucoma

Acute Glaucoma Shallow anterior chamber, red eye, hazy cornea, mid-dilated pupil

Posterior Vitreous Detachment Vitreous gel liquifies with age Eventually pulls away from retina May or may not tear a blood vessel or the retina when pulls away ~10% of retinal tear FLASHES OF LIGHT NEW FLOATERS

Posterior Vitreous Detachment If patient denies decreased vision or curtain/veil in vision, may wait until next day If decreased vision, lots of “little dots in vision” or “curtain/veil” in vision, or following history : Highly myopic (near-sighted) Lattice Degeneration s/p cataract surgery Recent posterior vitreous detachment (PVD) *** then see same day, ASAP

Retinal Tear May or may not be associated with retinal detachment Painless May or may not have a decrease in VA If blood in eye going to be blurry

Retinal Detachment “Rhegamotogenous” means due to tear(s) in retina Fluid in eye seeps out and breaks down seal to hold retina on May be partial or total

Retinal Detachment Sudden painless loss of vision May start as flashes/new floaters “Curtain” or “Veil” in vision or portion of side vision missing

Retinal Detachment If Macula still on = good VA If Macula already off Emergency surgery If Macula already off = bad VA Surgery within few days to week

Flashes of Light – Retina or Migraine Ocular Migraine One eye Pinpoint or lightning bolts that come from same direction Last a split second, but may repeat many times over hours to days No associated headache EMERGENCY Both eyes Usually swirling lights, perhaps colored, altered side vision Last 5-30 minutes and then over May or may not be followed by headache Not Emergent (other than to ease patients and dr’s minds)

Vein Occlusion Painless loss of vision Often associated with long-standing diabetes and hypertension Hard-walled arteries push down and compress squishy-walled veins Risk of neovascularization and glaucoma May be central vein or a branch vein If blood is not spilt into macula then patient may have no symptoms

Central Retinal Vein Occlusion (CRVO) Blockage along main vein draining eye Blood backs up and spills out into retina Swelling of optic nerve Vision very poor (20/200 or worse) See same day

Branch Retinal Vein Occlusion

Arterial Occlusion Sudden painless loss of vision “Vision kept getting dimmer and dimmer” Clot or thick blood blocks flow of blood into eye If temporary blockage and then passes, only get intermittent loss or dimming of vision “Amaurosis fugax” Need to consider underlying cause to prevent other problems like a stroke!

Central Retinal Artery Occlusion Blockage of main artery into eye No blood getting in = no oxygen Very limited time to get blood to eye or tissue suffocates and dies EMERGENCY!

Central Retinal Artery Occlusion

Branch Retinal Artery Occlusion Plaque breaks off from either carotid artery or heart valve and travels to eye Gets trapped in small arteriole of eye Usually leaves a long-term blind spot in area where there was no blood flow

Vitreous Hemorrhage Blood leaking into vitreous due to: Trauma Retinal tear Leakage from new blood vessels growing in the retina that are not supposed to be there Proliferative diabetic retinopathy Neovascularization after central or branch vein occlusion Wet macular degeneration where blood breaks out of retina and into vitreous Tumor in retina

Vitreous Hemorrhage

Vitreous Hemorrhage Usually painless, sudden loss of vision Emergent - See same day May look like “lots of dots” in vision or may be “hand motion” vision if blood is more dense Sometimes so much blood we cannot even see in to tell where it is coming from B-scan ultrasound to see retina

Exudative “Wet” Macular Degeneration Blood or fluid leaking into macula from abnormal vessels 1 in 10 “dry” become “wet”

Wet Macular Degeneration Symptoms: Rapid onset of visual loss Central blind spot Distortion of straight lines (Amsler Grid) No pain +/- History of Dry AMD See same day!

Macular Degeneration Central scotoma Amsler Grid

Exudative Macular Degeneration Lots of new therapies exist, but more effective when done right away Injections (Avastin, Lucentis, Eyelea) Need to get these consults into retinal clinic schedules as soon as possible Often need fluorescein angiography and/or macular OCT

Optic Neuritis Swelling of optic nerve Unilateral or bilateral Symptoms Slow deterioration of vision over hours to days Orbital pain, especially on eye movements Loss of color vision or light intensity See same day

Optic Nerve Edema Vision loss may be mild “smudge” to severe (20/400) +/- headache +/- neck pain +/- fatigue while chewing +/- scalp tenderness +/- malaise “sick feeling”

Optic Nerve Edema May be due to: Infection Multiple scleroris Inflammatory disease Severe “malignant” hypertension Lack of oxygen “ischemic” NAION AION – “Giant cell arteritis” – “temporal arteritis” Tumor along optic nerve or in brain Pseudotumor (intracranial hypertension)

Chief Complaint of “Diplopia” When gathering history on this patient, ask: 1) Happening with one eye or with both eyes open ? 2) Constant or intermittent ? 3) How long has it been going on ? 4) Do the images appear side by side, up and down, or diagonal from one another? 5) Recent trauma, headache, stroke, long term vascular disease (hypertension, diabetes)? 6) Any other muscle weakness? 7) Have they already had prism in their glasses? ** if not previously established cause for diplopia, then see same day!!

Causes of Diplopia Palsy of Extraocular Muscle Cranial Nerve 3, 4, 6 Sudden onset May resolve over 3 month period, may last forever May due to vascular disease, trauma, aneurysm, tumor, increased pressure in brain Trauma that restricts an extraocular muscle Blow-out fracture of orbit Usually have surgery to fix Decompensating Phoria Have had eye misalignment since young, but muscles no longer can compensate Gradual cause with sudden observation Orbital Disease Thyroid Eye Disease “Grave’s Disease” Orbital Mass

Questions? Thank you!